Rein Center New Patient Registration

1
Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Month
Day
Year
3
Gender* This field is required.
Female
Please Select
Male
Female
Other
4
Email* This field is required.
example@example.com
5
Where do you currently reside?* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Phone Number* This field is required.
7
What is the best way to contact you?
Email
Text
Phone - Ok to leave message
Phone - Do not leave message
8
Are you seeking in-person or online services?
No Preference / First Available Appointment
In-Person
In-Person - but ok with online if not available
Online
9
What services are you seeking? (check all that apply)* This field is required.
Psychotherapy
Psychiatry / Medication Management
Psychoeducational Assessment
Ketamine Treatment
Assessment for court related matter
10
Please tell us what you are seeking help with and your goals for treatment?* This field is required.
11
In the last year have your been hospitalized or gone to the emergency room for mental health concerns?* This field is required.
YESNO
12
Are you currently in treatment with a psychiatrist?* This field is required.
YESNO
13
Name of Current Psychiatrist?
First Name
Last Name
14
Psychiatrist's Phone Number?(If we need to contact them we will first ask you to sign a consent form)
15
Have you made a suicide attempt in the last 30 days?* This field is required.
YESNO
16
Have you had suicidal thoughts during the past 30 days?* This field is required.If you are currently in crisis please call 911 or go to your nearest emergency room as we can not accommodate urgent requests.
YESNO
17
We are sorry to hear that you are in distress. Please be aware, we are not available for urgent care. It takes a few weeks to book appointments and often we have a waitlist.

Please call 911 or go to your nearest emergency room.
18
Emergency Contact* This field is required.
First Name
Last Name
19
Emergency Contact's Phone Number* This field is required.
20
Do you have BCBS or Wellmark insurance?* This field is required.(We only accept BCBS / Wellmark)
YESNO
21
Insurance Plan Name
22
Insurance Plan Number
23
Are you cash pay?
YESNO
24
How do you plan to cover the cost of treatment?
25
Do you have Medicare or Medicaid?* This field is required.
YESNO
26
We do not accept Medicare or Medicaid. If you would like to opt-out and pay cash please hit "previous" button and select cash pay if you have not already done so.
27
Check all that apply:* This field is required.
Working
Student
Unemployed
Disabled
Retired
28
Check all third parties involved?
Lawyer or Legal Action
Worker's Compensation
Employment Related
Car Accident
Court Mandated
Referral by Doctor or Specialist
29
Name and Phone No. of Referring Physician
Clinic Name
Referring Physician
Phone No.
30
Permission to contact referring doctor or clinic.
YESNO
31
Signature
Clear
32
Guardian Signature (if under age 18)
Clear
33
Tags
Todo
In Progress
Done
Should be Empty: